 Welcome back to the Vermont House Human Services Committee. Again, this is, we're back from our pause on Thursday, February 24th. And this segment of our committee meeting will be focused on opioid overdose crisis response. The committee is poised to write or develop a committee bill on some things that we can do right now. But what we can do, we're looking to folks who are been working in this field and who what I would say have the expertise. And so this morning we have Marinelle Matthews, who is the public health equity manager for the city of Burlington and Andrew Seaman, who's the Vermont medical director. So Dr. Seaman of Better Life Partners, please go ahead. I will turn it over to the two of you to start us off. I will start us off if that works for you, Marinelle. I forgive me, I was just, we just learned about this last night and there was a request for a couple of slides. So I did add a couple of slides if the committee would like to see them if they would prefer oral testimony that's also fine. If the slides are what your testimony is, we don't need them, but you could send them to us and we'll post them. Great. Thank you. Otherwise, if you need them to clarify your remarks, that's fine too, and we can make you a co-host. Oral testimony is fine, I'll share my slides. So my understanding of this hearing is to try to nail down a couple of things that we can do that are lower barrier, faster, either deregulatory or other things that are going to be easier to accomplish. And so I'll try to focus first on those and I do want to make a couple of other comments as well if the committee is okay. So starting, one of the easiest things that I think we could do right now that would have an impact on our ability to engage people in treatment, maintain people in treatment and prevent overdose would be to remove the all prior authorizations on especially medications for opioid use disorder. And you have a bill currently sitting in your committee that does that, I believe it's H395. And here is the rationale for this. You may hear from the state that we don't need this and that we have a prior authorization process, but it only takes 30 minutes or something like that on average. And I just want to hammer in that from a treatment provider perspective, we would disagree that that's the actual impact of the prior authorization. So what we need to understand here is that fentanyl, which is now the vast majority of all opioids on the illicit market is just very different from heroin and other opioids in many ways. One, it sticks around in your body much, much longer than other opioids even though it's very fast acting and so people have to inject frequently in order to stay well that it's stored in the fat. And so you'll lose fentanyl over a substantial period of time. And so because of that, when you stop fentanyl and typically what you would typically do is when you're starting someone on buprenorphine, which is what we use in the outpatient community for treatment of substance use disorders or with opioid use disorder, you would tell someone to stop their drug and then they go into some degree of withdrawal, you give them buprenorphine and that helps them feel better. The challenge is that buprenorphine will kick drugs off the receptor, it can throw people into withdrawal called precipitated withdrawal. And with fentanyl that happens much more frequently as often in one study recently as 45% of the time. So almost one half of the time people coming into treatment who are started on Suboxone or buprenorphine that they're getting some, they're being made more sick by being started on buprenorphine. There are ways to address this many different ways. One of them is that, well, there are about four or five different new ways of starting people on buprenorphine that can help prevent this. You can start people on very tiny doses and ramp them up very quickly. You can start them on tiny doses and have them continue their drug use and ramp them up over a week. In the literature that we can't do it yet here, you can have them actually, you can give them something like a fentanyl patch and allow them to, which is a very safe regulated medication. We know exactly what's in it. And we can do this like start them on buprenorphine and over very, very slowly over a period of time. All of these things can dramatically impact how well induction is tolerated. And why that matters, it matters for a number of different reasons. One, obviously the person in question who's going on a bup induction who's starting on treatment, they're much more likely to stay in treatment if they don't feel sick, right? That's pretty obvious. If you feel sick, if you've been highly traumatized by withdrawal in the past, maybe in a criminal justice system or something like that, or maybe when your partner is abusive or something like that, that being in withdrawal in itself, it's more than just the sickness. It's a very re-traumatizing state. So people will very often fall off and start using again. But then there's also the perception. I mean, people talk to each other and if people think that bup is going to make them sick, they're not gonna come into treatment. This is a very low hanging fruit. Just get rid of these prior authorizations. They don't provide any benefit. Even if they only delay care in theory by 30 minutes or so, in practice, we don't write optimal dosing regimens because we know they're going to get declined. Maybe we won't be able to communicate this to the patient before they make it to the pharmacy. Maybe we have other pharmacy issues. There's often deviations from the actual prior author requirements. So it's kind of a no-brainer for me. So the specific things are, right now you can't go above 16 milligrams at any point without a prior authorization. And on induction, if you work for an organization like mine where I can have a phone from a phone call, I'm interested in treatment to being on meds in like 45 minutes, we need that to be immediate. We need to seize the moment. When someone is ambivalent about treatment, we need to be able to offer it in the moment. And that's what we can do at Better Life Partners. But even if you don't have that access, you still need to be able to get them on the right treatment right away. So get rid of that. We need to allow enough of the small doses of the medications so that we can do these newer induction techniques. And the thing that I think there's two important things. One, you'll hear, what about diversion? So diversion happens, we already have one of the highest diversion rates in the state despite these prior author restrictions. There is very, very little we can do to prevent diversion. If someone wants to divert, they can, bottom line. I don't care how much drug testing you have, et cetera, people figure it out, their system's in place. And I'm happy to discuss that more if you want. Two, diversion's not the problem. So in 2020, despite the fact that the streets are flooded with illicit buprenorphine, we had 1% of all deaths where the person who died had buprenorphine in their system at all and an even smaller percent where they thought it could have contributed to their death. On the other hand, fentanyl was an 88% of all overdose deaths in 2020. So it's just, even if it is out there and even if our intent is never to promote diversion, we don't want people to be selling their bup. It's not what's killing people. It's not what's causing overdoses. So I think the whole reason for the prior author is not about safety, it's not about anything else, it's about preventing diversion. Well, overdose from fentanyl is killing people, buprenorphine is not killing people. So we need to make buprenorphine easier to access. The second thing, and I have, in the slides I'll share with you, I have about 20 slides that share all of the details of this that you're welcome to look at. But buprenorphine is safe, even at very high doses, even going up very, very quickly. People are not having respiratory depression. It's a much, much safer medicine for a lot of different reasons that we probably don't have time to get into. So there's just no risk in this. There's no benefit of the prior author. I think we should get rid of it now. We aren't able to even talk to the drug utilization review board until September on this, how many people will be dead between now and then. So that's the easiest low hanging fruit I wanted. And I apologize, I talked more about that than I intended to, but I know it's a little complicated. The second thing is that I think that the access to methadone in the state is really inadequate. And that's both the number of different clinical sites, as well as the hours of operation. If you are in a clinic where federal regulations say you have to go every day, and it's only open till 10 o'clock, and we're also telling people, hey, you need to get a job and you need to get your life back together and all the things that promote recovery, that's inadequate. If you, in Chinatown County, and this is again, no fault of them, they have a lot of issues with being able to have enough staff and funding and all of that, but you can only do an intake between seven and seven 30 in the morning. That's problematic. And this is not just in Chinatown County, this is all around. So I think the very least, if we're not talking about more funding for methadone treatment, we need some sort of assessment for what are the needs, how can we address those needs? Because we know there are new sources of funding coming into the state. We also think that there'll be some more federal funding probably through SOR3 coming in. So we need to know how to use that. And the reason I bring up methadone just very briefly is we are seeing more and more people in the fentanyl era feeling like fentanyl works better. So the old data about equivalency of buprenorphine and methadone, it may or may not be true anymore in that fentanyl also binds to that receptor really tightly and also potentially people are more likely to fall off bup. And again, because that getting onto bup is so challenging, we really probably need either some new options and also more access to methadone. Next, I'll say that we need greater regulatory flexibility for treatment program. So there's this preferred provider status in the state where you have to apply, there has to be an RFP for it, you have to apply for it in order to become a provider that's compensated and allowed in the system really in a way that is feasible. And there are no options for that right now. There are, you can't even apply to become a new treatment provider. Despite that, hub and spoke has done amazing work and has really expanded access as compared to other states. And the number of people on treatment is stagnant and the system is not able to encourage more people to come into treatment. So we need new models of care and it's really challenging to do that if there are no opportunities to find and expand those new models. For instance, like we at Better Life Partners, we can't even apply to become a preferred provider despite that we're growing at 5% per week here because people love us because we don't judge them because we can get them on treatment immediately. And almost all of the referrals are coming from the people we serve. 90% of the referrals are coming from the people we serve. But and we'll keep being here, we'll operate at a loss and that's fine, but it's not just about us, it's about all of the other programs that wanna come in or even programs here, they wanna develop new ways of providing care that are a little bit maybe more nuanced or provide access to treatment in rural communities that Blueprint and the Havensburg system can. The only other things I'll mention, so very briefly, as I mentioned before, buprenorphine is safe and the version is not the problem. I think we need to remove the sunset provision on the buprenorphine decriminalization rule that was put in place. That's another easy thing that can be done. We've had that in place, we have never, we have not seen any evidence of harm. I think that was a great, really courageous effort by the legislature to pass that to begin with and I think we should just remove that sunset. And then I wanna thank the committee for one thing really quickly. So I see in the current budget increased funding for harm reduction centers. And so I know VT CARES and HRC and the AIDS Project of Southern Vermont have some increased funding. It's really direly needed. We work very closely with these organizations in a program we're rolling out in the SSPs and we really appreciate that. And then finally, I wanna say just two more quick things. I know this is not about the opioid settlement dollars and it's not really about the governor's proposed agenda or proposed budget for a substance use disorder treatment but I just wanna comment that both the committee makeup for or the advisory board makeup for the opioid settlement dollars and then a lot of the funding coming from the governor's office is about prevention. And I think right now in the middle of a crisis, absolutely prevention is important but we need reparative work. We need people to stop dying. And a lot of the things proposed and the composition of the advisory board is not really addressing the overdose crisis. It's addressing how do we prevent people 20 years down the line from falling into chaotic drug use and experiencing overdoses. So I just would in general, as you look at those measures and you look at those boards, really try to think about that lens of how do we focus on reparative work and then also think about the long-term. And so then the long-term things that I'll just say really briefly because I know it's really out of the scope for today but it's the window where I hope you can hear this which is that we really need real drug policy reform. And we had two good opportunities this year that passed us by. One was overdose prevention sites. We just shared in Comset this morning there was a picture of a time lapse of where the overdoses happened in Burlington and they were diverse and spread out and then just more and more and more centralized in that central Burlington area and also a very similar picture showed where needles were found and syringes were found over the Burlington area. And we need an overdose prevention site. Millions and millions of people have used these around the world. There's never been a single documented death. We have a great location for it. We have a willing team and we really need to be courageous on this. So I will just say that. And then the last thing is we also had this effort with decriminalization so I worked with decriminalization in Oregon where I came from. And that's a much longer story and I won't take too much of the committee's time but this is something that has dramatic effects on every element of preventing harms of drug use. It addresses stigma. It addresses all of the things that criminalization does to decrease people's ability to engage in life, engage in recovery, engage in employment and housing in being a parent and being a member of society and it provides no benefit. And we have an opportunity to do it and we should do it if not this year next year and I really would love to speak more on that but I wanna recognize the intent of today and so I'll step off and I'm happy to stay here for questions. Thank you. Thank you, Dr. Seaman. And I think we will go to Ms. Matthews and just so that you are, I appreciate your last comment and that is not just in the world of the legislature that belongs in judiciary. So that is not something that we will be talking about in terms of the decriminalization of drugs. Great, thank you so much. Yeah, thank you to the committee and thank you to Dr. Seaman. I actually would love to share slides if that's possible. It certainly is. I think you have to be made a co-host. Yeah, so I guess while that is getting set up, oh, there it goes, very, very quick. Thank you. I am Mariel Matthews. I use she, her pronouns. I am the public health equity manager at the city of Burlington, Vermont. I've been in this role for just over a year and have really learned a lot from colleagues and counterparts in this role, including Dr. Seaman. My work has always been focused on the role of the city of Burlington My work has always been focused on public health, always on equity. More recently, I've been focused on substance use and also focused on this intersection of substance use and racism. I also wanna talk a little bit about what my connection is to overdose just because I think it's important to share personal stories. My cousin died from an oxy-cotton overdose about 20 years ago, coming up on anniversary of that. In more recent times, my friend from high school has passed away from a heroin overdose, which has honestly caused me to be very scared of having a single child family because he was a single child. And I saw what his parents went through and I have a single child now, just to orient us in the place that we're in in terms of the impact of overdose and what it does to people's lives who are sharing that connection. So most of my work has been on the prevention side, how to prevent folks from getting into or from establishing a substance use disorder both on tobacco, cannabis, opioids and alcohol. I love being in this harm reduction area because I see the inside of all of how people criticize the prevention folks, which I didn't know that we were being made fun of, but it's really helpful for me to know all of the things that people find very dweeby and irrelevant that the prevention folks engage in. But I wanna point out where these things overlap because I think that that is really the crux of where we're gonna have some impact here. So when we talk about prevention, again, we're talking about preventing substance use disorder, preventing that establishment often is focused on children or teens or young adults that work. When we talk about harm reduction, we're more over here on this side of the spectrum talking about folks who have established substance use disorders, who are at risk of fatal overdose and who are often in crisis who need strong attention right now. And that's one of the things that I really wanted to call the committee's attention to is that no one knows better what those interventions are that would have an impact than drug users themselves. It is crucial for us to have the voice of drug users, specifically injection drug users at the table here. One of the things that I noticed in the proposed bill H711 about the structure of a committee to allocate resources for opioid abatement is that there's only one person recommended with lived experience as a member of that committee. That number should be dramatically increased because those are the people who know what would work, what has worked and what those innovative solutions may be. Something that we try to focus on in community stat is paying attention to that and centering those voices. Lived experience has many iterations, right? As someone who's had people close to me, as many of us have, someone who's had people close to me pass away from overdose, that's my lived experience. I know what that's like. I don't know what it's like to be an injection drug user and it's crucial to have those voices at the table. This is something that I think the committee could influence is changing who is deciding on the allocation of those resources and yearly it's decided by the same group of people. It's public health folks like myself. Now I know that I'm a nerdy prevention person but that is often who is at the table and it's important to recenter the voices of folks with lived experience. One huge opportunity for the legislature as Ania mentioned is creating a legal pathway for overdose prevention sites. So it's certainly help with the harm reduction side. This is acknowledging that folks are using illicit drugs and that there's not anything that we don't necessarily need to stop that but what we want to stop is their risk of death and dying. We cannot treat someone who has already experienced a fatal overdose. The point here is keeping people alive for as long as possible. So this is a slide that I had previously presented to the city council in Burlington just offering a vision of what overdose prevention sites look like. I know that this committee is familiar with overdose prevention sites. I believe you've had her testimony on them in the past but I wanted to also present some new understandings that I came upon this year honestly that these are really in part a future proof strategy as we start to see increases in methamphetamine use, other drugs coming on the market, new synthetic opioids, et cetera. With an overdose prevention site we don't need to know necessarily what is being circulated in the drug supply right now because anybody is welcome to come and use at the site and have medical assistance available to them should they need. It's also meshed with other services. So we know that one of the main barriers for treatment are include, I could name many but one is access to stable housing, another access to childcare, access to phones, access to transportation and all of those things can be coordinated at a well orchestrated overdose prevention site. As Dr. Seaman mentioned, there have been no fatal overdoses in any overdose prevention site that has been established despite fears they actually don't show any increase in crime in the geographic area around them. There's also a decrease in found syringes in the community which is certainly of interest in Burlington because we've had a huge uptick in the number of found syringes and importantly the increased treatment connectivity for folks with substance use disorder, SUD. And that is something that we're really interested in working on in Burlington. How do we get more people in treatment? And once they're there, how do we get folks to stay in treatment? So I'm gonna stop sharing these slides. I only hit three slides to show you but I will send those afterwards. I do have some other points that I wanna make in addition to establishing a legal pathway for municipalities to implement overdose prevention sites. It is, as Dr. Seaman mentioned, imperative that we increase access to methadone as an effective treatment for folks who are using fentanyl. Right now our methadone access is controlled mostly through the hubs in our hub and spoke model. And I think there's more community need than we can serve right now in our hub and spoke model. VDH, the Vermont Department of Health regularly publishes numbers on the number of people in care and the number of folks in the state who they think need care. The number of people in care right now or in treatment for overdose use disorder or for opioid use disorder is about 9,000 in some odd. And they anticipate or expect that there are actually 15,000 to 20,000 people who need treatment. So that's roughly six to 11,000 who aren't in treatment right now. And we could fix that with more access to methadone, easier access to care. One of those crucial points also as a point of entry are syringe service programs. Syringe service programs across the state are often underfunded. And they are really a crucial point on that harm reduction side for folks to access a trusted environment, get services that they need and potentially get connected to treatment. Lots of folks can come into treatment through their access with providers at syringe service programs. So it's not just about the syringe exchange but also about providing those auxiliary services and connections to other things that folks need. I also wanted to mention that, I believe Dr. Seema mentioned this as well, that it's difficult to induct on buprenorphine for folks. We have here our low barrier buprenorphine provider at Safe Recovery. And for folks who are using fentanyl, that is that transition to getting, becoming treated with buprenorphine can have withdrawal, can have someone go, someone may have to go through withdrawal during that period. And we need safe places for folks to do that. So I would suggest to the legislature to, or to the committee to prioritize identifying and suggesting to Department of Health and colleagues that we put emphasis on creating these places for safe induction onto medication, including buprenorphine. That means housing and monitoring for seven to 10 days-ish for many folks to get established on treatment. Another population of concern are, when folks exit the criminal justice system, a lot of folks are getting on to treatment in our criminal justice system while they're incarcerated, which is a good thing that they have access during that time. And they are at high risk for fatal overdose when they leave the criminal justice system or reenter society. It's very important at that point to have comprehensive services to help those folks with transition and maintaining their treatment. Tom Dalton from Vermonters for Criminal Justice Reform is working on a project that is supported by the city right now to specifically serve this population. The city is providing seed funding for this project. And we really hope to see a recovery center grow and hope to see services grow for that population. Lastly, two more points and then I will pause, but as a prevention person, I would be remiss to not mention opportunities to bring together both harm reduction and prevention. One of those is in preventing ACEs, adverse childhood experiences. The number one, the first recommended, so the CDC says that if we really want to prevent substance use disorder, ACEs are one of the best predictors of substance use disorder. The more ACEs that you have, the more ACEs you experience, the more likely you are to have a whole host of negative effects later in life. The first recommended CDC intervention on preventing ACEs is to create financial stability in a household, which is, and I love that recommendation in particular because it both affects the adults, right? The folks who are worried about money and it protects the children from having ACEs because of instability in the household. So I would really urge the legislature to consider interventions that would have an effect on ACEs. Those are things like making sure that not only everybody has the financial resources that they need, but housing, childcare, transportation, access to phones so that treatment can be coordinated. All of these things can be supported for folks who are current users of drugs and folks who are at risk of fatal overdose and that will also protect the next generation. All right, I'm so close here to finishing. Really, I need to commend my colleague, Scott Pavik, who works for the city of Burlington as the substance use policy analyst who's done a ton of work on prevention strategies, treatment strategies, retention and overdose prevention in general. If you'd like to learn more about any of these things, I really encourage you to reach out to Scott as a subject matter expert in this area and I'll share his email afterwards. The last thing here is about data. Data is so important. And one of the data pieces that we've had trouble getting access to is graduation data from treatment programs. It's really important that public health professionals and the community can understand how effective our treatment programs are and if they're not effective, like what can we do? I think we know a lot of the interventions that we could put in place to retain folks and help increase the efficacy of treatment. However, that data isn't publicly available and I think that the legislature or it's not consistently available and I think the legislature has a great opportunity to work with the Department of Health and require that treatment providers publish those data or that the Department of Health collect and publish this data. I believe that the Department of Health is collecting that data, but it's just not regularly available. So with that and thank you so much for the opportunity to speak and happy to take any questions. Thank you. Thank you very much. I appreciate the testimony of the slides and I wanna turn it over to the committee and for questions. Representative Rosenquist. Thank you. Just wanted to make sure I understood something. I think this was Dr. Seaman was talking about this, was the fact that you do morpheme already on what, I was definitely stuck out to say that, but anyway, that it has, and I just didn't hear it very well, but you said it actually has an effect on the fentanyl, or the fentanyl has an effect on it that is like 10 times worse than heroin by itself or something, did I get that right or not? So almost, so the issue, there are a couple of different issues with buprenorphine and fentanyl. One is that fentanyl, while it's a quick acting drug, it stores in your fat and so it sticks around in your body for a very long time. When we use buprenorphine to help people through treatment from opioid use disorder, it does two things. It comes in and it binds really tightly to the receptor that normally that fentanyl or that heroin or something would bind to, and it turns on the receptor a little bit. It makes people feel a little bit of the opioid effect, but it also blocks it. So then if someone comes in and uses fentanyl or uses other opioids that it bounces off and it's not working as well. But the other thing that happens is that if someone has fentanyl in their system still and you give them buprenorphine, it kicks off that fentanyl really quickly and they get sick. And so it induces that feeling of withdrawal. And so one of the challenges is that people who are started on buprenorphine and they were using fentanyl, and they don't even maybe know they were using fentanyl. Maybe they thought they were trying to use heroin, but fentanyl is in everything now, that they get sick and then they tell their friends that they got sick and neither they stopped treatment. Maybe they make it through, many people do, but it's a real challenge and it's a lot to ask. And so we need different ways of getting people under buprenorphine. And I like what Marielle said as well about, for some people, they might need a place to go where they can be supported by nurses physically or some other staff or individuals. So that's part of it. The other piece is that the fentanyl is very, very, it binds very, very, very tightly to their scepter compared to like heroin. And so it's a little easier if you're on buprenorphine, it's a little easier to feel the effects of fentanyl while you're on that buprenorphine or suboxone, then it would be say like heroin. And so it's even, it's a little harder to stay on treatment too. That is not a, that is not borne out in long clinical trials because we don't have them, but that is certainly the experience of people who use drugs. Thank you. Thank you, Madam Chair. Dr. Sieben, thank you so much for all of the testimony that you've provided. I wanted to just follow up on Representative Rosenquist's question and look at how do you, if you could just say a little bit more about how you see prior authorization as it is, whether it's that extra 30 minutes or I just need to hear a little bit more about how exactly that is a barrier that's linked to all of the different kinds of phenomenon with the withdrawal that somebody experiences and why the importance of removing that barrier and how that will have an impact on people's experience of receiving buprenorphine. Yeah, forgive me. Yeah, I appreciate that question. And I think it's based in part of the fact that I just spent 40 minutes showing a lot of data and slides and images to help a very large group of smart people try to figure this complex idea out. And so it's very understandable, this is complicated and so I, but having said that I did share those slides with you all, I already sent them out and so you can look at them and any questions, if you ever want me to come back and explain that kind of thing in more detail, I can, but in short, there are a few different things. One, the current prior authorizations require, or rules require a prior authorization for anything above 16 milligrams of buprenorphine. Having said that, we often need up to 24 milligrams on, or even sometimes higher to 32 milligrams by the sum data for their initial induction. And so because we're trying to get someone on treatment in the moment that they come in, we need to have confidence that we can write for the medicine dose that they actually need in the moment. And it doesn't matter if it's a 30 minute prior authorization process or a two day prior authorization process, which by the way, we have absolutely experienced two day prior authorizations, 30 minutes might be an average, but that's not our experience. It doesn't matter what we need is the confidence, both our confidence, our patient's confidence that we can write the dose, it's the right dose for them and that they'll get it every time. And it's not a different pharmacist on duty that day who doesn't quite remember that there's, you know, this difference, et cetera. So that's one thing. The second thing is that even though it's not currently written as such, we are often receiving denials for two milligram doses. So the small doses of buprenorphine, if we give more than three of those tabs in a day. So that's only six milligrams, but they say, well, if you're gonna give more than three, why don't you just use eight milligram tabs? But as I briefly mentioned, there are a lot of different ways to get people on bup. And if sometimes you need to give someone half of a milligram, you sure can't turn an eight milligram tablet or strip into a 0.5 milligram tablet or strip. And so even though it's not written as such, supposedly there's an exemption for these two milligram strips. Myself, my colleagues at Safe Recovery, other providers have had multiple denials for this. It's just the nature of prior authorizations. When you implement a bunch of complexity, there are gonna be errors. It's not about education. You can educate all you want, but then you'll have new staff come in. We just need to recognize that the prior off doesn't add benefit and it is certainly causing harm and it's a very low hanging fruit to remove. Dr. Seaman, is this prior authorization? Are there other states that we can look to who either have a higher bar or who do not have prior authorization? So I will say that in Oregon, we never had to deal with prior authorizations. In the two states that Better Life Partners currently works in, New Hampshire and Maine, they also do not have prior authorization. So of those three states that we're working in now, it's only Vermont that we have to worry about this. In fact, we have to change all of our practices for all the states just to work through. To make sure we don't, yeah. Thank you. So our neighbors, our very liberal neighbor is doing that, okay. Correct. I should say, let me give a caveat there. I don't know those rules as well, but I do know that at least the 24 milligram or the 16 milligram limit is not an issue in those two states. I should provide that caveat. Okay, thank you. Other questions, yeah. Just around methadone, is there prior authorization to have methadone, to have access to methadone? Or is that something you would even need? Like it, you know, in terms of the timeframe to have someone who wants to get on treatment first and getting them access to that methadone treatment? So it's a great question. I'm not an expert on that in Vermont. I don't believe there's a prior auth. The main barriers to methadone have to do with federal regulations, very old, like 1970s federal regulations on how methadone can be used, where it can be used, what kind of frequency you have to dispense it, and that sort of thing. But the prior auth, if it is there, it's not the barrier by any means. It's really a matter of all these federal regulations. But to clarify, I think the opportunity in front of us is a review of the hub and spoke model. Is that the right model to have just one central hub? Because I think that that is one of the reasons that the hub is the main, let me clarify the hub is the main prescriber of methadone. So folks from all over have to travel to this one clinic rather than having clinics in their areas that they have easier access to with different hours or whatnot. So I think that that is really the main thing that needs review right now is, is there an opportunity to expand methadone access via additional hubs and expansion of how our treatment coordination works here in Vermont? We know that not everybody's in treatment. Who needs treatment? And I have a feeling that it's not because folks aren't seeking it. Like usually a public health limiter, right? And achieving a healthy behavior is just the accessibility of the activity that you want to partake in. If treatment is inaccessible, of course folks are not going to be seeking out treatment. So I would urge the committee to consider a review of whether more methadone prescribing facilities could be an option forward for us. Thank you for clarifying that. And I would, if I may briefly add, the other thing that has changed since the hub and spoke model was created is that we now have the ability from a federal perspective to use mobile methadone distribution. So a van, just like we have harm reduction bands who distribute syringes, we have the ability to do methadone distribution through vans. And that is ideal for a rural environment like Vermont. So I think we just need a broader picture, revisitation of how the structure is created. Thank you. Just a quick follow-up and you may not be able to answer this, but what is the process for opening up another hub? And if you can't, that's okay, we... We can ask. We're not another but more. There are two components to that. There's the blueprint, the Vermont system, what is required from their perspective to open a hub. And then there's also the federal regulations. I think of the two, I would still say the federal regulations are probably the bigger lift, but the blueprint considerations for a hub are also quite complicated. And yes, we could certainly give you some names of people who could help you understand that process if you'd like. Representative Small and then Representative McFawn, and yeah. Wonderful. Thank you, Madam Chair. I have one clarifying question and then a different question. So to clarify, we have one hub in the state of Vermont and for, no, I don't know there, great. Clarify that one first. How many hubs do we have in the state? Eight. That could be a health department question, but I think we have eight. Great. And to clarify, you said that for intakes, it happens for a 30-minute window in the morning from seven to 7.30 a.m. Okay. Great. Thank you for that. To you, Dr. Seaman, you talked about something I never heard about, the ephentonal patch. And you said that there were barriers to using this method in the state of Vermont. What are those barriers? Yeah, so let me clarify that a little bit again. I'm trying to jam to overstuff this burrito, but so ephentonal patches are used for the treatment of pain and that's what they have an FDA approval for. And they are very potent and they distribute ephentonal for at a consistent rate over a 24-hour period. The barrier to using these patches is not specific to Vermont. It is something that there is just not an indication for this medication. But having said that, there are prior authorizations for medicines like this. So really any opioid agonist in this setting, there are some prior authorizations and that we wouldn't get payment for these medicines to use in someone for the purposes of treating opioid use disorder. So this is different from saying, oh, we need to take prior offs away from the medicines that are FDA approved to treat opioid use disorder. This is saying, it's one step further into thinking about how do we address this crisis? What about other models of doing this work with a safer medicine like fentanyl patch, which is produced by a pharmaceutical company and not in a basement lab somewhere or in an unregulated situation? What about using that, get someone stable on those medicines and then do your inductions from that perspective? So it's not a Vermont issue specifically, although the insurance payment issue, I think could potentially be addressed. I don't think you're gonna find the literature to get support for that today, but this is where we need to be moving. This is the direction we need to be moving. Thank you. Dr. Seaman, so in order to do that, what you were just speaking of in terms of the use of the fentanyl patch, that would require some different, I guess my question is, would that require some different indications of usage or approved usages of that? Since I'm familiar with its use as a pain management tool, not as a harm reduction tool moving towards substance use treatment. So it would require some definitional changes for the use of that, wouldn't it? So I wanna be really careful and not misspeak. And if the representative would like me to look into, who might be able to answer that question a little better, I absolutely will. But I will say that, yes, fentanyl is a fentanyl use to support a transition onto opioid use disorder treatment with Suboxone would be an off-label use. So there's no FDA indication. Having said that, we do much of our care off-label. That's not in itself an issue. The issue is that we wouldn't be able to get it paid for and I also would add that we would have to do a little bit more research into what some of the other DEA implications, for instance, would be, I don't know of them offhand. It's just the direction that as a medical community we're trying to move towards. And that's what they're doing in Canada, for instance, in many cases. Thank you. Representative Fon. Thanks. The fentanyl thing intrigues me. And in order for me to understand this, you're gonna have to help me understand why we would even consider using an addictive drug in treatment to get somebody off. Yeah. Thank you. And I will do my best on this. I think that, one, I don't want this to be too big of a distraction, because I think it's not my, this is not one of my current policy recommendations for this committee, but it's a really important question in general about using drugs that could cause an addiction or be associated with an addiction to treat an addiction. Why would we do that? And what I was specifically referring to was using a, basically you have someone on the street who's using opioids. They don't know what's in those opioids. They're assuming there's fentanyl in those opioids because almost everything has it, whether you call it heroin or fentanyl or something else, or some other fentanyl analog. And it could be sous-fentanyl or some even more potent medication, car fentanyl. And I think the point is, one, the current drug supply is poisonous. It is just extremely dangerous. The reason overdose deaths are going up is because in many, in a large part, because the drug supply is less safe. So if we just had heroin on the street right now, the overdose rates would be dramatically lower. And it's not just unsafe, but it's variable. So if you, this gets back to another conversation we had recently about personal use amounts. If you could get a felony for having two grams or two point something grams of heroin on you. And so you're like, okay, I'm not gonna do that. I'm gonna have a smaller amount on me. And I have to go out every single day or multiple times a day potentially to get enough drug. Then you are at risk of not having access to your supplier, needing to find a different supplier. Maybe that drug looks exactly the same, but it's three times as potent. You use the same amount and you die, right? And so what we're talking about in using a transitional medicine, whether it be fentanyl or something called slow release oral morphine or even just morphine, you know? And just another opioid is we know it's in it. We can titrate it, we can give you a little bit more until you're feeling stable. And then we get you onto the buprenorphine using some of these new ways we have of very, very slowly starting the buprenorphine and going up slowly so that people don't have to get super sick just to get on treatment. They can just get on treatment and then they can tell their friends, hey, it actually wasn't bad. That was great as opposed to I was so sick and I felt like I did, you know, last time I was arrested. Does that make sense? Yeah, it does. It makes sense to me. I just don't know if I agree with it. Yeah. I think it represents small. Oh yes, recognizing that we have limited time left apologies for opening that can of worms. So my curiosity, I couldn't curb away from it. Closing-ish question is it seems like Burlington is poised to open an overdose prevention site, but you mentioned that there were legislative barriers to that either now or in kind of follow-up testimony. Can you tell us what those barriers are and legislation that would prevent Burlington from implementing such program? Thank you, Representative Small for opportunity to speak about this. Basically, we would need municipal authority to make this decision to open a site in Burlington or in any other municipality. Rhode Island addressed this at the state level by charging their health department with setting up rules and regulations for future overdose prevention sites that open the pathway for them to, for any municipality to open an overdose prevention site. New York has addressed this by essentially assuring at the state level that they were not gonna prosecute New York City for opening their two overdose prevention sites which have thus far already saved hundreds of lives. So it's a combination of, there are multiple options how that pathway could be made, something it could be, here's the clear pathway for rules and regulations that need to be established and here's the authority who's gonna be in charge of that or it could be clarity that offers this decision up to the municipalities and accepts that the state puts the emphasis on saving lives rather than prosecuting for operating a site such as that within the municipality. Does that make sense? And that's very clear. Yeah, it's very clear. Thank you. Yes, Representative Rosenquist and you get the last question on this. Really? Well, maybe this is, you know, maybe a little bit of the point that I was just curious, what are the liability issues around opening up one of these sites relative to, let's say somebody passes away at the site, who is responsible, is the site responsible or municipality that is operating the site or what are the liability issues that have to be wrestled with and is this one of the impediments to opening these or why municipalities may be apprehensive? Yes, all of that. I don't think I can comment on that with the specificity that you're looking for. That is a question that we're exploring with our city attorneys, what would be the city's risk that we would be taking on. I would definitely urge the committee to explore that with the state as well, what would be the state's risk that you would be taking on if you allow these sites to operate. With the emphasis on saving lives, not on allowing people to pass away. Again, I would say that there have not been any fatal overdoses in any overdose prevention site around the globe. So just consider that as we're exploring this question because I do think that that is the main limiting question that prevents them from being opened, but the reality doesn't match the level of fear that we feel on the legal liability. If I may just... Yes, go ahead. 30 seconds. Thank you. I think it's important to summarize just in general, if there was a theme between what Marielle and I are saying, it's that we need to move from this model where we try to put as many restrictions as possible to protect on treatment options and use, et cetera, to protect people from themselves to something that's based on evidence and compassion, which is that the evidence shows we can't force people to stop using. It just doesn't work. It's not how addiction works. We can't force people to enter a recovery in a specific way and that by creating systems that are really hard to access, despite being there, if they're really, really hard to access, if I had to go to a methadone clinic at this very narrow window, chances are in my chaotic life, I'm not gonna be able to do that every day. I'm gonna get sick and then I'm gonna fall off. So how do we change our whole thinking around this too? How do we instead make it easier? How do we recognize the treatment is much safer than the other options that are out there? And how do we empower people to reach... I mean, really responding to Representative McFawn again. I think people don't have any control over what they use. People have a choice of getting sick or using what's out there. Let's give them other options that are better and safer for them and let's focus on keeping people alive first. And then we kind of work backwards and really fix some of these other societal issues that are creating this drug use crisis to begin with. I think Dr. Seaman, that was a perfect summary of the testimony that you and Ms. Matthews gave this morning and I do want to extend again the committee's thanks for your willingness to be here on such short notice and for the really thought provoking information that you've shared today and appreciate you both sharing your presentations and your slides and we will make sure that they're posted on our website. And again, our sincere thanks for being here this morning. And committee and those in their viewing public, this will end our morning session of the House Human Services Committee and we will be back here at 1.15.